By: Mr. Eros G.

Zuñiga
 State the objective of Accident
Investigation, Analysis and
Reporting.
 Describe the step-by-step
procedure involved in the
accident investigation process.
Assess an accident by properly
evaluating the underlying
factors that contribute to the
accident.
 Properly investigate a workplace
accident.
 Comply with the requirement of
the Occupational Safety and
Health Standards.
“People become injured,
disabled and sometimes killed
due to industrial accidents.
What can be done to prevent
these accidents from
recurring?”
  ADVANTAGES OF EFFECTIVE
INVESTIGATIONS:
They-
Described What Happened
Determined the Real Cause
 Described the Risks
 Developed Controls
Defined Trends
Demonstrated Concern
 THE CONDUCT OF ACCIDENT
INVESTIGATION

• The Investigator must:

– Have first basic understanding of
how accidents could happen
– Know the causal factors that lead to
accidents
“An unplanned event that may result
in personal injury or property
damage”
  ACCIDENT CAUSES

An Unsafe Act

An Unsafe Condition

 FAILURE IN
BEHAVIOUR
FAILURE IN ONE
OR MORE Lapses of
MANAGEMENT attention Mistaken
SYSTEMS Actions
Misperception
Hazop Audit Maintenance
Training Wilfulness Mistaken
Priority

Unsafe
Incident
Behaviour

Clearances Resources
Induction Procedures

ORGANISATIONAL YOUR
RESPONSIBILITIES RESPONSIBILITIES
  SOME COMMON EXCUSES ON
CAUSES OF ACCIDENTS:

 Carelessness

 Accident-prone
 Inattention (distraction)
 Negligence
 Not wearing safety equipment
 SOME COMMON EXCUSES ON CAUSES
OF ACCIDENTS:

Bad luck
Act of God
 Not thinking
 Laziness
 Taking short cut
 “Unsafe Act-Unsafe Condition”
vs. forces effect outside the workplace”
…”accidents occur within the system
and the worker is a part of the system.”
…”it must be understood and accepted
that the individual imports into a sterile
world of machines and work schedules,
influences, which occur outside of work
environment.”
…”while it is difficult to find solution to
what is perfectly natural occurrence (eg.
Bringing our problem to work) we can
not ignore the effect, forces outside the
workplace have on accident.”
  THE WORK SYSTEM

 PEOPLE
 PLANT AND EQUIPMENT
 PROCEDURES
 MANAGEMENT
 MATERIALS
 ENVIRONMENT
  THE WORK SYSTEM

…”When combined, these

elements allow for the
production process to be
carried out.”
..”Work environment is more than the
physical aspects of the Workplace
(eg. Lighting, noise, heat, air quality,
etc.).”
….”Given that a work is a system rather
than a collection of independent
variables, there is a sound reason to
believe that an accident is a breakdown
in a system rather than a fault in any
variable, e.g. the individual.”
..”When a worker has an accident, the
first consideration that an investigator
has to look into is what the work
system where an accident happened
look like.”
The Need to Inquire
 Purpose of Accident Investigation:
 Identify accident causes so that
similar accidents can be prevented
 Determine the “change” or “factors”
that produced an “error” that in turn
resulted in the accident
 AN INVESTIGATION SHOULD BE
ABLE TO ANSWER?
WHO was involved?
 WHAT happened?
 WHEN did it happened and WHAT are the
the contributing factors
 WHEN did the accident occur?
 WHERE did the accident occur?
 HOW can a similar accident be
prevented from happening?
 “ PREVENTION OR BLAME

“ If an accident occurs, are the

organization’s means of identifying
and correcting potential hazards at
fault?….

…. Not necessarily... The incident

may simply demonstrate the
organization’s limited experience”.
  CHARACTERISTICS OF GOOD
INVESTIGATIONS:

Yield information needed to:

 determine injury rates
 identify trends and problem areas
 permit comparisons
 satisfy legal requirements
  CHARACTERISTICS OF GOOD
INVESTIGATIONS:
 Identify the basic causes that
contributed directly, or directly, to
each incident
 Identify deficiencies in the production
and management system that
permitted the accident to occur
 Suggest specific corrective action
alternatives for the management
system
“The purpose of conducting investigation is to
establish causes.”
Blame can result into:
 Witnesses not revealing all of the circumstances
and events surrounding the accident
 Deliberate obstruction, or provision of false
information
 Removal of relevant information documents or
evidence
 For the accident investigation to be successful in
identifying all of the causes it will be necessary to
establish:

 Events leading up to the incident

 The system of work being carried on
 The instruction given for the work
 Variation from instruction or safe work systems
Workplace condition such as lighting, floor
surfaces, stairs treads and handrails, warning
signs, temperature, weather if incident
occurred outside, etc.
 The exact location of the incident
 The materials in used or being handled
 The type of transport or equipment in
use
  Facts of the incident itself

 The state of the systems and the actions

that occurred at the moment
 The persons directly involved, and those
involved at a distance, if any
 The tools, equipment, materials and
fixtures directly concerned
 The time and nature of any injury
 WHO SHOULD INVESTIGATE?

“ The size and make-up of the

investigation team is usually dictated
by the accident’s seriousness or
complexity”
EXAMPLE: WHO SHOULD INVISTIGATE?
(RISK BASED APPROACH)
WHO TYPE OF INVESTIGATION &
RISK INVESTIGATES REPORT
Supervisor  Report only
1 -6  Use UIR/IR
 e.g . Broken Door Handle
7 - 10 Supevisor/Manager  Report & Investigate
 Use UIR/IR
 Use "Basic Investigation
Guidelines
 e.g. First Aid Injury (bruised
elbow)
11 - 30 Business  Report & Investigate
Manager/Factory  Use UIR/IR but add supporting
Manager documentation
 Use "Basic Investigation
Guidelines
 e.g MTC /Potential Lost Time

31 - 50 Country Manager  Report & Investigate

 Fully documented report
 Use "Significant Incident Tool Kit"
 e. g. Falling off an MMU
51- 100 GMT, e.g. Asia  As immediately above
Manager or SHE  e.g. Major Magazine Fire
Team, e.g. Asia
Pacific SH&E
Manager
CONDUCTING AN INVESTIGATION

The Team Leader

• Should be chosen as soon as possible
• Should have the experience and the
authority to get the job done
CONDUCTING AN INVESTIGATION
His duties include:
 compilation of the report
 presiding over meetings
controlling scope of the team
activities

 The Health & Safety Representative

CONDUCTING AN INVESTIGATION
 QUESTIONING THE WITNESSES

 2 Types of Witnesses
 Eye Witness
 Hearing Witness
 INTERVIEW TECHNIQUES
 Basic approach to “investigation
interviewing”:
 Conduct the interview in private at
workplace
 Put the interviewee at ease, don’t
hurry things
 Ask for the interviewee’s story of
what version of what has
happened
Only ask necessary questions
 Repeat the interviewee’s story as
you understand it
 Close the interview on a positive
note and thank the witness
CONDUCTING AN INVESTIGATION
 Conducting the Interview at the Scene
of the Accident
 “Usually the main advantage in
interviewing at the scene is that it
usually assists the memory of the
person being interviewed if he/she
can refer or point to physical
conditions at the scene of the
accident”
CONDUCTING AN INVESTIGATION

 Only Ask “Necessary” Questions

 Ask Open Questions
 Repeat Story as you Understand it
 Close the Interview Positively
 ORICA EXPLOSIVES PHILIPPINES INC.

INCIDENT INVESTIGATION REPORT

FORKLIFT INCIDENT

1. SUMMARY

1.1 DEPARTMENT CONCERNED: 1.2 CONTRACTOR INVOLVED:

Order Service & Dispatch Santies Trucking
1.3 LOCATION OF INCIDENT: 1.4 DATE OF 1.5 TIME:
Mariveles Zigzag OCCURRENCE: +/- 0800 H
04/4/00

INJURY PROPERTY DAMAGE PERSON INVOLVED

1.6 PROPERTY DAMAGED: 1.10 PERSON WITH MOST
Forklift CONTROL OF
EQUIPMENT DURING
THE INCIDENT:
Mr. Arnel Sambile
1.6 None 1.7 Estimated Cost:

+/- P 10,000.00
1.11 OCCUPATION:
Driver
1.8 CAUSE OF DAMAGE: 1.12 TRUCK NUMBER:
Equipment fall TJL 651
1.9 NATURE OF DAMAGE:
 Fork chain Wheel Assembly
broken
 - Slight scratches on body
paint

2. DESCRIPTION OF THE INCIDENT

The truck left BASECO Pier at around 0745 H, loaded with

OEP forklift machine with serial no. 517721. The forklift
was anchored to the body of the truck with a nylon rope of
around 1/2-inch in diameter. The forklift four wheels were
apparently blocked with wooden chock and the equipment
parking brake was engaged. Mr. Joey Valdoz who was
overseeing the loading of explosives in MV Takatori
ensured that the equipment was tied off, although he did
not realize that the sling size is too small. During the
transport of the forklift to the Factory by the supplier, it was
anchored using big metal chain.
1. ANALYSIS

The immediate cause of the incident was apparently the sudden braking of the
truck while climbing uphill in order to avoiding collision with a descending
speeding vehicle. On the other hand, the underlying causes for the equipment to
fall was improper anchoring of the forklift and undersize sling, which attributed
further to having no standard procedure on anchoring forklift to the truck during
transport.

(Please see attached Why Analysis of the incident).

2. EVALUATION

2.1 Loss Severity Potential

Serious - There could have been a major damage to equipment and should
there was a vehicle following the truck, it might also inflict serious damage to
the other vehicle and likewise serious injury to the driver and /or its passenger
/s.

2.2 Probable Recurrence Rate

Frequent - Should there will be no standard procedure of anchoring the

Equipment during transport, a similar incident can occur on its future
transportation.

3. PREVENTIVE ACTION

ACTION BY WHO BY WHEN

3.1 Establish procedure on anchoring forklift during DIS Before next
transportation from the Factory shipment
to the pier or when being loaded to the truck. (07/00)
3.2 Establish procedure on anchoring forklift during DIS Before next
transportation from the Factory shipment
to the pier or when being loaded to the truck (07/00)
5.3 Train supervisors and drivers on the procedure DIS Before next
shipment
(07/00)
5.4 Ensure proper anchoring is done and the right DIS/ Always every
type of sling is used before transporting Supervisors shipment
forklift as per standard procedure
5.5 Ensure truckers are given safety induction on DIS Always every
transport operation shipment
5.6 Audit truck condition and transport DIS/EKP/MG Always every
6. ATTACHEMENT

Why Analysis of the Incident

Prepared by: J M PERFIÑAN

SH&E MANAGER
 Rule 1052 - Special Provision
 1052.01
 Rule 1053 - Report Requirements
 1053.01
 1053.02
Rule 1054 - Keeping Records
Rule 1055 - Evaluation of Disability
 Rule 1056 - Measurement of
Performance
 1056.01 - Exposure to Industrial
Injuries
 1056.02 - Determination of
Employee-Hours Exposure
 Rule 1056.03 - Measurement of
Injury/Illness
 Disabling Injury/Illnesses Frequency
Rate (FR)
 Disabling Injury/Illnesses Severity
Rate (SR)
 Average Days Charge Per Disabling
Injury/Illnesses
 TO SUMMARIZE:
Effective Investigation
 Accident
The Work System
The Synoptic Accident Mode
The Actual Investigation
Conducting an Investigation
Legal Requirement
WORKSHOP:
ACCIDENT INVESTIGATION & REPORTING
Write an investigation report of of an
accident, involving a company
personnel service vehicle inside the plant
premises, during the night shift. The
CAR hit the corner of a building injuring
the DRIVER, suffering a medical
treatment case (MTC). The car sustained
a major damage. No passenger during
the time of accident.
 WORKSHOP:
ACCIDENT INVESTIGATION & REPORTING

Format:
 Description of the accident (Basic
information, WHO, WHEN, WHERE, WHAT,
HOW)
 Accident analysis; causation - root causes
 Recommendation to prevent recurrence;
(RECOMMENDED ACTIONS, BY WHO, BY
WHEN)
 Case #1
• The Accident:
Driver J. Cruz and J. Reyes were unloading bulk feed
from their truck into the feed bin of house #5. The truck’s
feed compartment was on a dumping tilted position. The
truck was directly under the electrical high-tension wires,
with 1.2kva, supplying power to the poultry houses. While
unloading, J. Cruz noticed the feed was not flowing
smoothly inside the compartment. He climbed above and
looked into the manhole. When he raised his hand, he
momentarily forgotten the electric wire above him. His
nape got in contact with the wire and shock threw him into
the manhole. Helper J. Reyes, who was standing at the
tail of the truck was also thrown against the compartment.
Continuation of accident case #1
J. Cruz suffered burns on the nape and buttocks.
While J. Roxas suffered cut on the forehead.
The high tension wire diagonally crossed the road
fronting house #5. Because of the terrain and the sag,
the wires has a clearance of 18 feet from the ground
level at the point in front of house #5 or where the truck
was parked. The truck has a clearance height of about
12 feet, untitled, from the ground. If the bulk feed inside
the truck compartment gets stucked, the driver dislodge
by means of using poles through the manhole.
According to Mr. Rodriguez, Farm Superintendent,
this is the second time incident of this nature happened
on the same spot.
 Case #2
• The Accident:
In a ship repair company, a welder was working on
the side of a barge. The platform on which he was
standing was almost touching the water. The platform
was supported by rope on each end. While he was
operating the electric welding machine, a motorboat
passed by creating waves that caused the welder to off-
balanced. He held on to the electric cable of the welding
machine, still, fell into the water and got drowned. His
body was recovered only the following day. Investigation
revealed that the victim was an assistant to the regular
welder, who was absent. When asked for written
procedure, the company could not present one.
Injury Frequency and Severity Rates

These are important to enable a company

or operating unit to determine how
effectively its employee injury problem is
being met and what progress is being
made
 What is “Injury Frequency Rate”?

• Is based upon the total number of

disabling injuries such as deaths,
permanent total, permanent partial and
temporary total disabilities which occur
during the period covered by the rate.
Injury Frequency Rates are used to determine:

• Whether the number of work injuries in any

particular operating unit is lesser or greater than
in other operating units in the same industry.
• Whether a given operating unit is having more or
less injuries when compared to a previous
period of time and similar operations.
• Whether an industry has a better or worse injury
experience than other industries or than the
average for all industries.
Injury Frequency Rate Computation

First Step : Gather Information

• Obtain the number of employee – man-
hours of exposure, preferably direct from
the time records. When this cannot be
done, the exposure may be estimated on
an annual basis as follows;
– The average employee who works a 40-
hour a week can be assumed to worked a
total of 2,000 man-hours per year.
 • Multiply the number of full-time employees by 2,000
• Estimate the number of hours worked by part-time
employees and the number of hours overtime.

• Add these two figures and you have a fairly accurate

estimate of the total annual number of hours in which
employees have been exposed to injury for that year.
• Obtain the number of disabling injuries from the
employee injury record. If such record is maintained, an
estimate may be developed by adding the disabling
injury reports and fatalities that have occurred during a
period of time covered by the number of man-hours
exposure
 Second Step: Calculate the Injury –
Frequency Rate

IFR = Number of Disabling Injury x 1,000,000

Total Number of Man-Hours of Exposure
 What is “Injury Severity Rate”?

• Is based upon the total number of

disabling injuries such as deaths,
permanent total, permanent partial and
temporary total disabilities, plus the total
actual days of the disabilities of all
temporary total disabilities which occur
during the period covered by the rate.
Injury Severity Rate Computation

• First Step: Gather Information

– Obtain the man-hour of exposure by the same

method used for computing injury frequency
rate.
– Obtain total days lost due to injuries for the
corresponding period of man-hours exposure.
• Second Step: Calculate the Injury-Severity

ISR = Total Days Lost + Time Charges x 1,000,000

Total Number of Man-Hours of Exposure